Drug therapy: patient compliance

Evaluation of a computerized reminder system in the enhancement of patient medication refill compliance

This study evaluated the use of a computerized patient profile combined with a reminder system to increase refill compliance of patients on cardiovascular medications. There were 311 patients randomly assigned into one of three groups. Patients in group 1 were monitored for refill compliance only. Group 2 patients received a postcard reminder; group 3 patients received a telephone call reminder. Refill compliance was monitored via the computerized patient profile system for a period of three months. Data collection included refill compliance, reasons for noncompliance, and the number of prescription medications for each patient. There was a significant difference between the overall mean rate of compliance between the control and intervention groups. An increase in refill compliance for all groups occurred over three months. There was no significant difference in compliance between the treatment groups. Overall, the medication reminder system appeared to be effective; however, modifications in the system should be pursued.

Compliance of pediatric and adolescent cancer patients

Compliance with self-administered therapy in pediatric and adolescent patients is not always complete. Noncompliance may result in erroneous conclusions about the efficacy of a given therapy and lead to unnecessary tests and alteration of treatment regimens. To examine the causes of noncompliance, 46 cancer patients aged 2.5 to 23 years (mean age, 6.85 years) and 40 parents were extensively interviewed at 2 weeks, 20 weeks, and 50 weeks post-diagnosis. The results of self-reported compliance were corroborated by serum bioassay of the prescribed medications. A significant correlation between the age of patient and compliance with chemotherapeutic agents and nonchemotherapeutic medications was found (P less than 0.05 and P less than 0.02, respectively), with adolescent patients being compliant less often. Over the course of therapy, compliance among patients decreased, but not significantly. A significant negative correlation was found between compliance and the number of children in the family. Compliers and noncompliers did differ significantly in how well they understood instructions concerning how to take their medication (P = 0.04). No significant correlations between compliance and stage of the disease, number or type of drugs used, complexity of the regimen, degree of satisfaction with information given to the patient, understanding of disease, treatment, or belief in medication efficacy were found. The main reasons given for noncompliance were forgetfulness, busy schedules, and nonavailability of medication. More compliers than noncompliers were in agreement with their parents regarding who was responsible for the administration of the medication. Compliance is a complex and multifaceted issue which interrelates with a large number of medical and social factors.

Interviewing skills training--a study

A randomized investigation was conducted to study the effect of a structural 10-week course on the development of interviewing skills of first year medical students. The experimental group (16 students) received interviewing skills training based on the Developmental Helping Model as described by Carkhuff in 1982. The comparison group (16 students) received traditionally focused training with emphasis on gathering information about the patient's presenting problem through the use of open-ended questions. The dependent measure was interviewing skills level. Each student was videotaped with a simulated patient during the initial (pre-test) and final (post-test) sessions of the course. Tapes were rated by blinded reviewers according to Carkhuff's five point scale of Developmental Helping. No pre-test differences were found between groups. At post-test, the experimental group showed significantly higher ratings. This data suggests that teaching specific interviewing skills is more effective than non-skill oriented training for development of medical students' ability to interview patients.

Patient compliance and medication perception

The problem of patient/client noncompliance with regimens of prescribed medication is addressed, with attention to the incidence and illogical nature of this behavior. The psychological theory of cognitive dissonance is suggested as appropriate to an understanding of some aspects of noncompliance because medicinal preparations represent stimuli that are not necessarily neutral. A medication's perceptual properties may have important and specific meanings for patients or clients that may support or detract from compliance. Recent research and empirical evidence that reflects on this concept are reviewed. With further efforts, it may be possible to enhance compliance through perceptual engineering.

Comparison of controlled-release diazepam capsules and placebo in patients in general practice

A multi-centre, randomized double-blind parallel study was carried out to compare the efficacy and tolerance of a single daily dose of controlled-release (CR) capsules of diazepam (10 mg and 15 mg) with placebo under conditions close to those of general practice. All patients between 16 and 60 years of age, presenting an anxiety syndrome as a result of neurotic disturbance, for whom benzodiazepine treatment was indicated for at least 3 weeks, were accepted for the study. The results from 231 patients (119 on placebo, 55 on 10 mg and 57 on 15 mg diazepam) were analyzed after 1 and 3 weeks of treatment. Complaints were found to have improved after 1 week and 3 weeks in the controlled-release diazepam groups whereas the corresponding results with placebo were clearly less favourable. After 1 week, and even more strikingly after 3 weeks, evaluation of the general effects of treatment showed better results with diazepam than with placebo. The obviously higher rate of drop-outs on placebo confirmed its less reliable effect. The controlled-release capsules were well tolerated and notably better than placebo. The most frequent side-effect reported on diazepam was fatigue, and this was probably due to a relative overdosage from use of a standardized dose throughout treatment. Other reported side-effects could not definitely be ascribed to the drug. At the end of a week, successful results were achieved in 48.2% of the patients on controlled-release diazepam compared with only 14.3% of those on placebo. After 3 weeks, these figures were 73.2% and 30.3%, respectively.

Assessment of cognitive deficit in geriatric patients. A study of physician behavior

A crucial factor in promoting a vigorous quality of life in the aging population is assessment and treatment of cognitive deficits. A very high percentage of delirium and at least 20% of dementia is eminently treatable. This study of patients over 65 years of age admitted to a university general hospital reveals that 79% of cognitive deficits were missed by the examining physicians. Furthermore, in 394 examinations of 165 patients, only four mental status examinations were recorded. A clear-cut cognitive deficit on admission was predictive of later acute episodes of confusion. The global techniques of evaluation deserve remediable action by medical schools and hospital training programs if the medical care of the elderly is to be improved.

Influence of medical and premedical education on important personal qualities of physicians

Three interrelated personal qualities of physicians are believed important for sensitive patient care and optimal individual adjustment to the stresses of medical practice: maturity, social competence, and moderation in aggressive competitive (exaggerated "type A" behavior). Despite widespread recognition of the importance of these qualities by patients and physicians alike, they have commonly been neglected in favor of scientific and scholastic excellence in the selection process for medical schools. In addition, some aspects of premedical and medical education may actually have an adverse influence on these personal qualities of future physicians. More emphasis in premedical and medical education on the importance of physicians' noncognitive abilities, and more individualized feedback to students and residents on the interactions between their personal qualities and their success and happiness as physicians, are needed.

Concordance ratings of community adjustment for older psychiatric inpatients

Concordance between psychiatric patients and significant others for pre- and posthospital adjustment has been a problem. This is especially so for older patients. Self and other ratings for younger and older psychiatric patients were compared at admission (younger n = 5729, older n = 1088) and for community adjustment after treatment (younger n = 1914, older n = 492). Community adjustment ratings by self and others were used on admission and highly sensitive residual scores accounting for pretreatment differences were used after discharge. Substantial discordance for pretreatment ratings between patients and significant others was noted. For posttreatment adjustment, ratings were more concordant. In both cases age was not an influencing factor. Finally, background and treatment factors that differentiated concordant from discordant younger and older patients were noted. These reflected societal patterns for age.

Choosing antimicrobials. Factors to consider, available agents

Many factors are involved in choice of an antimicrobial agent. Cost has become a matter of increasing concern. Of course, overall expense for the hospitalized patient includes costs of tests for monitoring for toxicity as well as administration costs, which are affected by the dosing frequency. A reasoned choice necessitates knowledge of the place of newer agents in the therapeutic armamentarium and of some new applications of well-established drugs.

A drug survey--precepts and practices

An attempt has been made to quantitate drug consumption in a conurbation. The prescribing habits of physicians, self medication rate and therapeutic classes of drugs purchased have been evaluated. The study indicates that some of the prevailing practices in the area are unhealthy. The high self medication rate, faulty prescribing habits of physicians and liberal dispensing methods of pharmacist need to be viewed with concern. The wide gap between the precepts and practices prevailing among practitioners, the use of potent medicines without proper medical advice and the uninhibited sale of scheduled drugs over the pharmacy counter require careful consideration. If such unhealthy trends persist iatrogenic problems may surface in the near future. The physician, pharmacist and the public need to cooperate to create the proper pattern of drug usage.

Prescription drug advertising: trends and implications

Prescription drug advertisements which appeared in two leading American medical journals in 1972, 1977 and 1982 were analyzed to discover possible trends in advertising. The 5016 ads examined showed that ads for the diuretic-cardiovasculars, especially the beta-adrenergic blocking agents and the slow channel inhibitors, as well as the analgesics, had increased, while ads for the anti-infectives and tranquilizers had diminished. The average amount of space allocated for each ad had increased. On the average, most ads (69%) depicted neither male nor female patients in their graphics, and a trend of increased neutrality was observed. When the hormones were excluded, an average of 21% of the ads showed male patients and 10% showed females. Since a relationship was discerned between the leading drugs advertised and the leading prescriptions filled, it was concluded that advertising does have some effect on the prescribing behavior of practitioners. The findings suggest that great investment in advertising is necessary in order to achieve high levels of sales for such drugs as Valium (diazepam) which do not have a clear-cut ameliorative effect on a specific physiological condition. On the other hand, it was suggested that saturation advertising would not significantly enhance the sales of such drugs as Dyazide (triamterene and hydrochlorothiazide) because of its well established therapeutic value in the control of hypertension. Ten advertising companies, on the average, had purchased 67% of all advertising space and five had purchased almost half (47%). The same two pharmaceutical companies were among the top five advertisers and the same five were among the top ten for the three years studied.

Patterns of drug taking in patients with chronic airflow obstruction

A questionnaire on the pattern of drug taking was completed by 185 patients with chronic airflow obstruction. Of these, 49% admitted to taking their prescribed therapy regularly and 33% could be regarded as being fully compliant. The use of increasing numbers of drugs was not accompanied by a fall in compliance. Regular drug taking was better in patients (particularly females) with asthma than in patients with chronic bronchitis and emphysema. During acute exacerbations of airflow obstruction, excessive use of bronchodilators beyond the recommended increase in medication was rare; indeed, underuse of therapy in this situation was commoner. These conclusions must be regarded as tentative since the questionnaire was not validated by repeat interviewing or measurement of drug usage.

The potential use of markers in drug development

There are at least three recurring questions crucial to the drug and drug formulation development processes that could be addressed by marker methodology: (1) Is the assessment of an effective dose or dose regimen correct? (2) Is an inadequate response or nonresponse secondary to pharmacology or to inadequate compliance? (3) Can various formulations provide significantly better therapy for certain populations? Characteristics of an ideal marker system would include: Simple and reliable to measure. Able to yield reliable evaluation of routine adherence in single or multiple dose situations. Biologically inert. Samples for measurement can be obtained unobtrusively. Samples are painless to obtain (for patient and clinic staff). Absorption and kinetic characteristics approximate those of the therapeutic candidate. Able to be presented in multiple formulations. Current methodology for addressing these questions is far short of ideal. Therefore, if marker methodology that lacks the limitation of present technology could be developed, it potentially would find wide use during the drug development process.

Prescription drugs and the elderly. Strategies for effective drug prescribing and use

The author explains why the elderly are particularly at risk for problems of noncompliance with prescribed drug regimens and describes some innovative strategies that can be used to prevent or reduce both inappropriate prescribing by physicians and noncompliance among the elderly. These strategies can be applied by health professionals providing or monitoring drug therapy for the elderly (primarily physicians and pharmacists) and some can also be undertaken by the elderly working in close collaboration with clinical pharmacists. The paper concludes with an examination of the potential role of continuing education in ameliorating some of the problems discussed here.

Older age research non-responders: an inpatient "profile"

Examined the differences between older research non-responders and older completers and between older research non-responders and younger ones. As part of a large cooperative Veterans Administration study, a sample of 619 older non-responders were compared to 964 older completers and also to 4,731 younger non-responders on basic demographic and treatment factors, as well as on self-rated adjustment dimensions. Among other factors, results show that older non-responders tend to be substance abusers, to be "loners," but have equal or better adjustment ratings than older completers; and among other variables, older non-responders tend to be "first timers" in psychiatric hospitals, to have greater treatment expectations, and to rate themselves with better adjustment in many areas relative to younger non-responders.

Nadolol compared to propranolol for treating chronic stable angina pectoris

In order to determine the relative efficacy and dose equivalency of propranolol four times a day and nadolol once daily for the treatment of stable angina pectoris, ten patients were studied in a double blind randomized placebo controlled crossover study. Total daily doses of propranolol and nadolol were determined by titrating until an equivalent degree of reduction in the heart rate response to exercise was achieved. At these doses, the treadmill exercise time to 0.1 mV of electrocardiographic ST-segment depression was increased from 248 +/- 75 seconds on placebo to 405 +/- 56 seconds on propranolol (p less than 0.05) and 471 +/- 46 seconds on nadolol (p less than 0.01). Also, the mean frequency of angina decreased from eight attacks per week on placebo to three on propranolol and nadolol (both p less than 0.05). In six of the ten patients, the effective total daily dose of propranolol and nadolol was identical, and the dose ratio for all ten patients was 1.17:1, propranolol to nadolol. However, individual dose titration is recommended when switching from propranolol four times a day to nadolol once daily because of the dosage variability noted in 40 percent of the patients.

Comparative pharmacokinetics of ketoprofen derived from single oral doses of ketoprofen capsules or a novel sustained-release pellet formulation

Nine healthy male volunteers took part in a crossover study to compare the pharmacokinetics of ketoprofen after administration of a single oral dose (200 mg) of ketoprofen as 'Orudis' capsules or encapsulated sustained-release pellets, 'Oruvail'. The mean +/- standard deviation values for highest observed plasma ketoprofen concentrations were determined by high performance liquid chromatography to be 23 +/- 11 micrograms ml-1 at 0.82 +/- 0.18 h after dosing with ketoprofen capsules and 3.5 +/- 1.0 micrograms ml-1 at 4.9 +/- 1.0 h after dosing with sustained-release pellets. The apparent ketoprofen elimination half-lives after these treatments were 3.3 +/- 1.2 h and 8.4 +/- 3.4 h, respectively. The systemic availability of ketoprofen was essentially the same after each treatment. Administration of sustained-release pellets (containing 200 mg ketoprofen) once every 24 h is predicted to produce similar average and markedly higher minimum plasma ketoprofen concentrations than are produced by ketoprofen capsules (100 mg) every 12 h, and similar minimum plasma ketoprofen concentrations to those achieved by dosing ketoprofen capsules (50 mg) every 6 h. Once-daily administration of a non-steroidal anti-inflammatory agent has an obvious therapeutic advantage over more frequent dosing. This study suggests that the sustained-release pellet formulation described herein is a suitable formulation for once-daily administration of ketoprofen.

Penicillin compliance in splenectomized thalassemics

Compliance with penicillin prophylaxis after splenectomy was studied in 42 thalassemic children and adolescents. Urine samples were tested five times per patient for the presence of penicillin by the Sarcina lutea inhibition test. Only 7% of patients were found to be absolute noncompliers, while an additional 14% had a compliance considered to be insufficient. Noncompliers tended to have been splenectomized more than 5 years before, while couples of affected siblings were uniformly full-compliers. No relation was found with age, presence of healthy siblings in the household, chronic disease or previous severe infections. Knowledge of the risks of severe infection after splenectomy was uniformly good. We conclude that compliance with penicillin prophylaxis in splenectomized thalassemics is good (79%) and that close contact between patients and medical staff is important in its promotion.

Psychiatric consultations in a general hospital: compliance to follow-up

Noncompliance rates for office visits following a psychiatric consultation in a general hospital may be lower than previously reported, although noncompliance is still a significant problem. There is a significant drop-out rate within two follow-up sessions. Few patients entered psychotherapy. Geriatric patients preferred only medication follow-up. The possible reasons for the lower noncompliance rate in this study are discussed.

Effect of a new potent H2-receptor antagonist on meal-stimulated gastric acid secretion and serum gastrin concentration in duodenal ulcer patients

We evaluated the effect of 20-, 40-, 60-, and 80-mg doses of SKF 93479, a new H2-receptor antagonist, on food-stimulated gastric acid secretion in duodenal ulcer patients. Medications were given as a single oral dose in the morning with a breakfast meal, and acid secretion was measured by in vivo intragastric titration in response to four blended steak meals infused into the stomach at intervals over a 24-hr period. A breakfast meal was infused immediately after medication; a luncheon meal was given 5 hr after drug, and a dinner meal was instilled 10 hr later. A second breakfast meal was infused 24 hr after medication. For comparison, the effect of 300 mg cimetidine, given as normally prescribed (with meals and at bedtime), on acid secretion was also studied. Food-stimulated acid secretion was inhibited in a dose-related manner by each of the four doses of SKF 93479. The antisecretory effect was most dramatic following the luncheon meal, and there was still significant (P less than 0.05) inhibition of acid secretion at the dinner meal with all doses of SKF 93479. With the second breakfast meal 24 hr after medication, the 80-mg dose alone achieved significant (P less than 0.05) inhibition of acid secretion. Inhibition of acid secretion was correlated positively with blood SKF 93479 levels. When compared with placebo results, serum gastrin concentration, measured 5 and 10 hr after medication, was significantly higher (P less than 0.05) with SKF 93479.

Efficacy of once daily penbutolol in chronic stable angina. An objective comparison with long-acting propranolol

The effects of penbutolol (40 mg daily) and long-acting propranolol (160 mg daily) were assessed in 26 patients with chronic stable angina in a placebo-controlled randomised double-blind crossover study with 2-weekly treatment periods. In addition to conventional subjective assessment, serial multistage treadmill exercise was used to obtain objective data on drug efficacy and 24-hr ambulatory electrocardiography performed for diurnal heart rate analysis. The mean exercise time of 6.3 +/- 0.5 (SEM) min on placebo increased to 7.3 +/- 0.6 min on penbutolol (P less than 0.01) and to 7.9 +/- 0.5 min on propranolol (P less than 0.001). The pre-exercise resting heart rate was 73 +/- 2 beats/min on placebo and decreased to 63 +/- 2 beats/min on penbutolol (P less than 0.001) and 58 +/- 2 beats/min on propranolol (P less than 0.001). The maximum exercise heart rate was similarly reduced by both drugs and there was a corresponding reduction in peak exercise double product. The time-corrected maximum ST segment depression was reduced by both drugs and neither produced a delay in ST segment recovery. Both drugs effected significant reductions in ambulatory maximum hourly heart rates throughout 24 hr. The lowest observed heart rate on penbutolol was 40 beats/min and 34 beats/min on propranolol. Penbutolol is an effective antianginal agent with a profile of action similar to that of propranolol.

Spouse contracting to increase antabuse compliance in alcoholic veterans

Developed and evaluated a home-based contracting program to determine its effect on the compliance rates of discharged alcohol patients to a disulfiram (antabuse) regimen. The three comparison groups included (a) no contract/no recording; (b) contract/recording; and (c) contract/recording plus instructions for positive reinforcement. Twenty-five patients who had been treated in a behaviorally oriented inpatient alcohol dependence treatment program and who lived with a significant other (i.e., spouse, sibling, parent) participated in the study. At the end of the 3-month period for which the disulfiram was prescribed, those Ss who were involved in contracting and recording reached criterion more frequently than those who were in the minimal treatment group. Furthermore, 84% of this S sample were abstinent at the 3-month follow-up according to collateral reports. The discussion centers on the use of home-based contracting as an inexpensive alternative to other, more costly disulfiram programs. Additional methods for obtaining measures of reliability on self-report of disulfiram usage also are discussed.

Individualizing theophylline dosage: evaluation of a single-point maintenance dose prediction method

A dosage prediction method to estimate theophylline clearance and dose requirement was evaluated in 22 outpatients with partly reversible obstructive airways disease. The steady state theophylline dose required to achieve a target concentration (Css) was predicted using a single serum theophylline determination 8 h after a single oral test dose. In 17 nonsmoking patients a mean absolute deviation of 8.2% (range 0.0-21.7%) between predicted and observed Css was found, and in 5 smoking patients the mean deviation was 34.0% (range 2.2-53.8%). In 17 healthy smokers the single-point method was found to predict theophylline clearance at a sampling time of 8 h with a prediction error of 11.3 (range 0.8-25.3%) compared to the clearance determination using the area under the curve. In addition, a numerical simulation program to assess the influence of absorption, elimination and sampling time on predictive accuracy showed that the method could be successfully applied to a patient population with elimination rate constants between 0.07 1/h and 0.25 1/h, allowing a mean prediction error of 15%.

Medication noncompliance: systematic approaches to evaluation and intervention

Medication noncompliance is a significant problem in medical practice, but many intervention strategies developed for noncompliant patients (such as tangible rewards, contingency contracting) are not practical for the large numbers of patients seen by private practitioners on an ongoing basis. Based upon a review of the literature concerning the key determinants affecting compliance, the authors have developed a practical, rational, and systematic approach to assessing medication compliance that may serve as a guide for psychiatrists in formulating consultation recommendations, in liaison teaching activities, and in clinical psychiatric practice. Special emphasis is placed upon the identification of psychiatric syndromes that may negatively affect compliance. Implications for compliance-related research in consultation-liaison psychiatry are also discussed.

Compliance of hypertensive patients with pharmacological treatment

Failure of compliance with drug treatment is a major problem in all diseases requiring long-term therapy. The incidence of noncompliance is variously reported as between 5% and 60% in well-conducted investigations in hypertensive patients. Direct (objective) methods give a higher incidence of noncompliance than indirect (subjective) methods. Among factors associated with noncompliance, the complexity of the treatment regimen and the nature of the doctor-patient relationship are important; few demographic characters among the patient population can be identified. Improvement of noncompliance depends on understanding these facets of the problem.

A comparison of once and twice daily atenolol for angina pectoris

We have studied the effects of four doses of atenolol in 11 patients with stable angina pectoris using a symptom-limited exercise test and angina diaries. The doses 100 mg twice daily and 50 mg, 100 mg and 200 mg once daily were given double-blind and randomised within patients following run-in on placebo. Measurements were made 12 hours after the last twice daily dose and 24 hours after the last once daily dose. Exercise tolerance was improved by 40-74% and exercise duration before the onset of angina by 61-94% (P less than 0.01). Maximal heart rate was reduced further by a total daily dose of 200 mg than by lower doses, but no extra benefit was derived by giving the drug twice daily. The largest increase in exercise tolerance was obtained during treatment with 50 mg once daily. Atenolol was shown to be an effective anti-anginal agent when given once daily, and there were no major differences between the doses studied.

Compliance and the health belief model: a challenge for the liaison psychiatrist

Noncompliance or nonadherence to prescribed medical regiments is a widespread problem. The behavior of noncompliance is complex, requiring an analysis based upon theoretical constructs. We review the Health Belief Model (HBM) as one such construct that may aid in understanding the problem. The four essential ingredients of the model include (1) a perception of susceptibility to disease, (2) a belief that the impact of this disease will affect him/her biologically and/or psychosocially, (3) a belief that the potential benefits of the regime outweigh the risks of the disease and its treatment, and (4) an ability to surmount barriers to treatment. The HBM has been shown to have construct validity and has provided a means of exploring practical and cost effective methods for reducing noncompliance and perhaps morbidity and mortality associated with failures to follow up on recommended medical procedures. Moreover, the general problem of noncompliance provides a unique opportunity for students of human behavior to interact constructively with their medical and surgical colleagues.

Psychotherapy and pharmacotherapy: the challenge of integration

The use of psychotherapy and pharmacotherapy in combination remains a neglected area of study. In spite of evidence validating the combined treatment psychiatrists often avoid this approach. When combined treatment is employed insufficient attention may be devoted to the important interactive effects. Patients may react to the prescription of medication with a variety of transference feelings such as acceptance, rejection, manipulation and narcissistic injury. Discussion of interpersonal issues precipitated by the use of medication can improve not only the doctor-patient alliance but also the patient's symptomatic experience. The initiation or discontinuation of medications must be carried out with sufficient attention to the patient's realistic concerns and transference distortions. The neglect of a negative transference reaction aroused by the prescription of a medication can result in a resistance to treatment. Case examples and discussion in the article illustrate such phenomena. Psychiatrists need to be aware that their decision to prescribe medication may be influenced by their own unconscious conflicts surrounding the use of medication. They may prescribe or fail to prescribe motivated by their latent fantasies. Attention to the interactive effects of combined therapy is viewed as essential in order to aid patients in the dual goals of symptom alleviation and enrichment of interpersonal experience.

Managing medication and compliance: physician--pharmacist--patient interactions

Behavior characteristics of both health care practitioners and patients are discussed in terms of their effects on the delivery of care and the rational use of drugs. Three modes of behavior are described: the instrumental, the customary, and the command modes. Although most physicians follow the customary mode, an instrumental approach is recommended both for patient interactions and for drug selection. Patient education is often insufficient, and physicians tend unjustly to blame the failure of a treatment regimen on the patient's lack of compliance. An "index of risk" is presented to help spot potential drug defaulters, as are clues in the behavioral diagnosis.